Clinical skills in early postgraduate medical trainees: patterns of acquisition of confidence and experience among junior doctors in a university teaching hospital

Athletic Trainers' Familiarity, Comfort, Knowledge, and Recognition of Social Determinants of Health

CONTEXT

Social determinants of health (SDOH)-education, transportation, housing, employment, health systems and services, economic status, and physical and social environments-influence patient outcomes; therefore, athletic trainers (ATs) need to understand and address these factors. However, little is known about how ATs perceive SDOH or how knowledgeable they are about social factors that contribute to patient health and well-being.

OBJECTIVE

To evaluate ATs' familiarity and comfort with SDOH and their perceived knowledge and recognition of SDOH.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Our survey was distributed to 17 000 ATs; 1829 accessed it (access rate = 10.8%), and 1694 completed it (completion rate = 92.6%, AT experience = 15.2 ± 10.6 years, age = 36.6 ± 10.8 years).

MAIN OUTCOME MEASURE(S)

The survey included multipart questions that evaluated ATs' perceptions of their familiarity, comfort, and knowledge about SDOH. Data were summarized using descriptive statistics.

RESULTS

Few respondents (4.1%, 70/1691) reported being extremely familiar with SDOH. Most indicated being moderately familiar (45.0%, 761/1691), minimally familiar (34.7%, 587/1691), or not familiar at all (16.1%, 273/1691). For questions about comfort, few described being extremely comfortable (3.5%, 59/1691) with SDOH, and most reported being moderately comfortable (35.4%, 598/1691), minimally comfortable (41.1%, 695/1691), or not comfortable at all (18.6%, 314/1691). For questions about knowledge, few indicated being extremely knowledgeable (2.7%, 46/1686) about SDOH, and the majority described being moderately (36.8%, 622/1686), minimally (41.8%, 704/1686), or not knowledgeable at all (18.6%, 314/1686). Over half of ATs accurately categorized 8 of the 9 SDOH listed in the survey, and 22% endorsed more correct than incorrect items.

CONCLUSIONS

A majority of ATs perceived their familiarity, comfort, and knowledge about SDOH to be moderate to low, which may reflect the relatively recent emphasis on SDOH in athletic health care. Because SDOH can have a major effect on patient health and well-being, strategies should be developed for educating ATs about SDOH. Developing strategies to increase comfort with SDOH in patient care is critical to ensure that those factors that can be addressed at the patient level are identified and managed.

Evaluation of Self-Perceived Confidence and Competence in Oral Surgery among Final Year Undergraduate Students in Greece

OBJECTIVES

 Oral surgery is an integral part of dentistry that deals with the diagnosis and management of pathology of the mouth and jaws that requires surgical intervention. The aim of undergraduate studies in oral surgery is, upon graduation, to be confident and competent to treat without assistance surgical cases in the spectrum of general dentistry. This study evaluates the senior Greek dental students' self-confidence and self-perceived competence to undertake cases within the scope of oral surgery. Evaluation of clinical experience gathered during training and self-perceived confidence and competence in generic oral surgery skills is included.

MATERIALS AND METHODS

 The present study was a questionnaire survey conducted during the academic year 2018-2019. The questionnaire comprised three sections. Section 1 included demographic data and four closed-ended questions concerning numerical data about procedures that they had already performed or observed, section 2 included four questions concerning their self-perceived competence to perform basic surgical techniques, and section 3 included 10 clinical case scenarios.

RESULTS

 One hundred and twenty-seven students participated in the study. Among the basic surgical skills, students were most confident with suturing, and they were least confident with bone removal. Students from the Aristotle University of Thessaloniki (AUTH) tend to show higher level of confidence compared with students from the National and Kapodistrian University of Athens (NKUA) in most questions.

CONCLUSION

 Greek graduate dental students report moderate levels of self-confidence in oral surgery. A realistic approach in increasing self-confidence and competence in oral surgery would be the focus on preclinical training in generic elementary surgical skills, in combination with increased observational sessions of oral surgery procedures or outreach training.

A KSA system for competency-based assessment of clinicians' professional development in China and quality gap analysis

BACKGROUND

We aim to create a holistic competency-based assessment system to measure competency evolution over time - one of the first such systems in China.

METHOD

Two rounds of self-reported surveys were fielded among the graduates from the Shantou University Medical College: June through December 2017, and May through August 2018. Responses from three cohorts of graduates specializing in clinical medicine - new graduates, resident physicians, and senior physicians - were analyzed. Gaps between respondents' expected and existing levels of competencies were examined using a modified service quality model, SERVQUAL.

RESULTS

A total of 605 questionnaires were collected in 2017 for the construction of competency indicators and a 5-level proficiency rating scale, and 407 in 2018, for confirmatory factor and competency gap analysis. Reliability coefficients of all competency indicators (36) were greater than 0.9. Three competency domains were identified through exploratory factor analysis: knowledge (K), skills (S), and attitude (A). The confirmatory factor analysis confirmed the fit of the scale (CMIN/DF < 4; CFI > 0.9; IFI > 0.9; RMSEA ≤ 0.08). Within the cohorts of resident and senior physicians, the largest competency gap was seen in the domain of knowledge (K): -1.84 and -1.41, respectively. Among new graduates, the largest gap was found in the domain of skills (S) (-1.92), with the gap in knowledge (-1.91) trailing closely behind.

CONCLUSIONS

A competency-based assessment system is proposed to evaluate clinician's competency development in three domains: knowledge (K), skills (S), and attitude (A). The system consists of 36 competency indicators, a rating scale of 5 proficiency levels, and a gap analysis to measure competency evolution through 3 key milestones in clinician's professional career: new graduate, resident physician, and senior physician. The competency gaps identified can provide evidence-based guide to clinicians' own continuous development as well as future medical curriculum improvements.

Procedural Training in Pediatric Emergency Medicine Fellowship: What Are We Teaching and What Do Fellows Need to Learn?

BACKGROUND

Life-saving procedures are rarely performed on children in the emergency department, making it difficult for trainees to acquire the skills necessary to provide proficient resuscitative care for children. Studies have demonstrated that residents in general pediatrics and emergency medicine lack exposure to procedures in the pediatric context, but no studies exist regarding procedural training in pediatric emergency medicine (PEM). Although the Accreditation Council for Graduate Medical Education (ACGME) provides a list of procedures in which PEM fellows must be competent, the relevance of this procedure list to actual PEM practice has not been studied.

OBJECTIVES

This study sought to determine whether PEM fellowships currently provide sufficient exposure to the skills most relevant for practicing PEM physicians.

STUDY DESIGN

Data were collected via anonymous electronic survey from physicians who graduated from PEM fellowship between 2012 and 2016. Survey items measured respondents' comfort with performing critical procedures, and their perceptions of the necessity of knowing how to perform each procedure in their current practice environment.

RESULTS

A total of 133 individuals responded to the survey. Respondents unanimously agreed that 18 of the 36 procedures required by the ACGME are necessary to know in their current practice environment. For the remaining 18 mandated procedures, there was significant disagreement among respondents both as to the necessity of the procedure in current practice and respondents' degree of comfort with performing each procedure.

CONCLUSIONS

Among recent PEM fellowship graduates, there is significant variation in comfort with performing ACGME-mandated procedures. These data highlight important opportunities for curricular enhancement in the procedural training of PEM physicians.

[ToSkORL: self- and objective assessment of examination skills in the head and neck region]

Hintergrund

Ein zentrales Ziel des Medizinstudiums ist der Erwerb theoretischer und praktischer Kompetenzen. Es mangelt jedoch an Evidenz, wie der Erwerb von Kompetenzen in speziellen Untersuchungstechniken gemessen werden kann. ToSkORL (Teaching of Skills in Otorhinolaryngology) ist ein Projekt, das die studentische Selbstwahrnehmung ihrer Kompetenz bei speziellen Untersuchungstechniken der Hals-Nasen-Ohren-Heilkunde und des Kopf-Hals-Bereichs aus didaktisch-wissenschaftlicher Sichtweise beleuchtet.

Methodik

Im Rahmen des Untersuchungskurses erfolgte eine standardisierte mündlich-praktische Prüfung zu neun verschiedenen Untersuchungstechniken. Vor der Prüfung erfolgte eine Evaluation der studentischen Selbsteinschätzung mittels Fragebogen, die Prüfung wurde mittels Checkliste durch die Prüfenden standardisiert geprüft. Selbst- und Fremdeinschätzung nach der Likert-Skala wurden korreliert. Die neun Untersuchungstechniken wurden jeweils 42-mal von insgesamt 91 Studierenden in gegenseitiger Untersuchung durchgeführt.

Ergebnisse

Die Selbsteinschätzung der Kompetenz in den Untersuchungstechniken variiert erheblich, insgesamt schätzten Studierende ihre eigene Untersuchungskompetenz weitgehend unabhängig von Alter und Geschlecht meist realistisch ein. Studierende mit einem hohen Interesse an der Hals-Nasen-Ohren-Heilkunde gaben bessere Selbsteinschätzungen an, neigten jedoch auch eher zur Selbstüberschätzung. Bei Untersuchungen des mittleren Schwierigkeitsniveaus ergab sich die größte Divergenz von Selbst- und Fremdeinschätzung.

Schlussfolgerung

Die studentische Selbsteinschätzung ist ein geeignetes Instrument zur Messung der Untersuchungskompetenz in der Hals-Nasen-Ohren-Heilkunde. Es sollte ein besonderer Fokus auf die Lehre vermeintlich mittelschwerer Untersuchungstechniken gelegt werden, da diese am stärksten über- und unterschätzt werden.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00106-021-01097-y) enthält zwei Mini-Clinical-Exam(CEX)-Evaluationsbögen für Studenten und Untersucher. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte scannen Sie den QR-Code, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

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Athletic Trainers’ Experiences Working With Athletes With a Physical Disability in School-Based Sports

This study describes the experiences of over 500 school-based athletic trainers (ATs) and their familiarity, knowledge, comfort, and confidence working with athletes with a disability. ATs’ experiences in managing the health care of school-based athletes with a physical disability are unknown. Half of the respondents indicated experience providing services to these athletes, while 70% indicated little to no specific training/education. About half of the ATs reported being comfortable and confident in managing the care of athletes with a physical disability, while a quarter reported being knowledgeable. Findings suggest that experience helps provide ATs with comfort and confidence in caring for these athletes, but educational opportunities are still needed.

Simulation Training for Operational Medicine Providers (STOMP): Impact of a Comprehensive Skills-Based Curriculum for Military General Medical Officers

INTRODUCTION

A standardized training curriculum designed for general medical officers (GMO) titled Simulation Training for Operational Medicine Providers (STOMP) was recently developed to educate and improve GMOs' procedural skills through directed feedback prior to assuming duties in an operational environment. This study aimed to determine the impact this novel curriculum had on GMOs'confidence levels in 21 core privileges covering eight different subspecialties while stationed at Naval Medical Center Portsmouth (NMCP).

MATERIALS AND METHODS

A cohort study from 2015 to 2017 was designed to address our specific aim to examine if the implementation of the STOMP curriculum increased GMOs' confidence levels. Fifty-seven participants enrolled in the study. The GMO case group completed the STOMP curriculum (n = 22), while the control or GMO self-study group (n = 35) did not complete the curriculum. Six months after starting clinical practice at NMCP, both groups completed an online survey that assessed their confidence level in performing each core privilege using a 5-point Likert scale. Scores were analyzed using a Wilcoxon Mann-Whitney test. Research data were derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol number: NMCP.2016.0010.

RESULTS

Participants demonstrated a statistically significant increase in self-rated confidence scores (p < 0.05) in nine core privilege skills: punch biopsy, shave biopsy, excisional biopsy, removal of otic foreign body, removal of nasal foreign body, removal of ocular foreign body, tonometry, incision and drainage of a thrombosed hemorrhoid, and reduction of simple closed fractures and dislocations.

CONCLUSIONS

These findings suggest that a novel and recently developed standardized simulation training curriculum entitled STOMP improves the confidence levels of early career physicians' in several primary care procedural skills and is an ideal adjunct to traditional lecture-based teaching prior to independent practice in a primary care environment.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

BACKGROUND

Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill.

METHODS

One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE).

RESULTS

Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE.

CONCLUSIONS

A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

The effectiveness of the internship in meeting established learning objectives: A qualitative study

OBJECTIVE

To identify and explore variations in intern (Postgraduate Year 1 doctors) exposure to clinical activities defined by an established early postgraduate curriculum within the contemporary health service environment.

METHODS

A mixed methods study was undertaken in seven health services comprising (1) a questionnaire regarding interns' exposure to a range of clinical activities within a two-year early post-graduate curriculum and (2) group interviews with intern supervisors and managers to explore barriers and facilitators of interns' clinical exposure.

RESULTS

One hundred and eleven interns completed the questionnaire and seventeen intern supervisors and managers participated in group interviews. Interns' exposure to early postgraduate curriculum activities varied significantly, with participation in patient emergency management and procedures being undertaken less frequently than interns wished. These findings were consistent across different regional settings. Of three mandatory terms, exposure to curriculum activities was greater in medicine and emergency medicine than in surgery.

CONCLUSIONS

Junior doctors' participation within the complex contemporary health service environment is constrained by barriers relating to clinical governance frameworks and health system performance, particularly in high-risk clinical activities. Solutions will require structural approaches to internship reform to ensure that placements provide the necessary safe clinical experiences required for intern training.

Self-Reported Training Adequacy, Experience, and Comfort Level in Performing Schizophrenia-Related Clinical Skills among Psychiatry Residents and Fellows

OBJECTIVE

In the context of an educational program on schizophrenia for psychiatry trainees, this survey study analyzed associations between self-reported training adequacy, experience in providing patient care, and comfort level in performing schizophrenia-related clinical skills. The influence of the education on comfort level was also assessed for each skill.

METHODS

Survey respondents were psychiatry residents and fellows who participated in a schizophrenia education program at an in-person workshop or through online videos recorded at the workshop. In a pre-program survey, participants reported their experience in providing schizophrenia patient care and rated their training adequacy and comfort level for performing seven clinical skills involved in diagnosing and treating schizophrenia. The post-program survey included items for reassessing comfort level in performing the skills.

RESULTS

Across the seven clinical skills, the proportion of respondents (n = 79) who agreed or strongly agreed that their training was adequate ranged from 29 to 88 %. The proportion of high ratings for comfort level in skill performance ranged from 45 to 83 %. Comfort level was significantly associated with training adequacy for all seven clinical skills and with experience in providing patient care for four skills. For all skills, comfort level ratings were significantly higher after versus before the educational workshop. Commonly indicated needs for further training included education on new therapies, exposure to a broader range of patients, and opportunities for longitudinal patient management.

CONCLUSIONS

Psychiatry trainees' self-reported, disease-specific training adequacy, experiences, and comfort level have unique applications for developing and evaluating graduate medical curriculum.

How Knowledge Relates to Confidence in Orthopedics and Emergency Medicine Regarding Return to Sport and Rehabilitation in Foot and Ankle Trauma

OBJECTIVE

The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopedics on 5 common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience.

DESIGN

An online survey was used to gather the information using scenario-based open and closed questions.

PARTICIPANTS

A total of 102 health care professionals, who regularly deal with sports injuries, were recruited. These included consultant orthopedic surgeons with a subspecialty interest in foot and ankle surgery, orthopedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopedic registrars, senior physiotherapists, and junior physiotherapists.

SETTING

The participants were drawn from various health care institutions in the North East of England.

RESULTS

Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation program design than either set of registrars. For 2 of the case scenarios, there was a significant difference in scores between either orthopedic consultants or ESPs and registrars (p < 0.05). For total score, there was a trend for extended scope practitioners to score higher than both sets of registrars, but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given.

CONCLUSIONS

The most significant area of gaps in knowledge among the 2 groups of registrars was in the specifics of rehabilitation programs. There was markedly higher confidence with greater seniority. Registrars in emergency medicine and orthopedics are likely to benefit from case-based teaching in sports injury rehabilitation.

Using longitudinal mixed methods to study the development of professional behaviours during pharmacy work-based training

Recent longitudinal investigations of professional socialisation and development of professional behaviours during work-based training are lacking. Using longitudinal mixed methods, this study aimed to explore the development of professional behaviours during a year of intensive work-based (pre-registration) training in pharmacy. Twenty trainee pharmacists and their tutors completed semi-structured interview and professional behaviour questionnaires at four time points during 2011/2012: months 1, 4 and 9 during training and 4 months after registration; tutors participated in months 1 and 9. Interviews were analysed thematically using template analysis, and questionnaires were analysed using ANOVA and t-tests. Self-assessed (trainee) and tutor ratings of all elements of professional behaviours measured in questionnaires (appearance, interpersonal/social skills, responsibility, communication skills) increased significantly from the start of pre-registration training to post-registration. Some elements, for example, communication skills, showed more change over time compared with others, such as appearance, and continued to improve post-registration. Qualitative findings highlighted the changing roles of trainees and learning experiences that appeared to facilitate the development of professional behaviours. Trainees' colleagues, and particularly tutors, played an essential part in trainees' development through offering support and role modelling. Trainees noted that they would have benefited from more responsibilities during training to ease the transition into practising as a responsible pharmacist. Longitudinal mixed methods can unpack the way in which professional behaviours develop during work-based training and allow researchers to examine changes in the demonstration of professional behaviours and how they occur. Identifying areas less prone to change allows for more focus to be given to supporting trainees in areas where there is a development need, such as communication skills and holding increasing responsibility.

Confidence in Procedural Skills before and after a Two-Year Master's Programme in Family Medicine in Gezira State, Sudan

Many postgraduate family medicine training programmes have been developed to meet the worldwide dire need for practicing family physicians. This study was conducted in Gezira state of Sudan in a "before-and-after" design in the period of 2010-2012 with the aim to assess improvements in candidates' confidence in performing certain clinical skills. A self-evaluation questionnaire was used with a five-grade scale (1-5) to assess candidates' confidence in performing 46 clinical skills. A group of 108 participants responded for both the "before" and the "after" questionnaire: the response rate was 91% (before) and 90% (after). In general, a positive progress trend was detected. The mean skill value for all skills was 3.23 (before) and 3.93 (after) with a mean increase of 21.7% (P < 0.001). Male students scored constantly higher than females both before and after completing the master's programme, while females showed a higher percentage in progress. Scores in certain medical disciplines were higher than others. However, disciplines with low scores in the beginning, such as psychiatry and ophthalmology, showed the highest progress percentage. The results show a significant increase in confidence in performing procedural skills designed in the curriculum of the GFMP master's programme.

Invasive medical procedure skills amongst Foundation Year Doctors - a questionnaire study

Objectives

Competency in practical skills is an important aspect of training for medical doctors. This questionnaire survey aimed to investigate if the current Foundation Year trainees have performed several practical procedures of importance and their level of confidence in carrying them out unsupervised.

Design

Questionnaire study.

Setting

Five National Health Service hospitals in England.

Participants

A total of 103 Foundation Year trainees responded to the survey (73 FY1s; 30 FY2s).

Main outcome measures

Percentage of trainees who have performed these skills and their average level of confidence.

Results

The percentage of trainees who have performed these skills and their average level of confidence (scale of 1 to 5) are as follows: intubation (32%, 1); chest drain (33%, 1); central line (26%, 1); femoral line (23%, 1); peripheral line (28%, 1); lumbar puncture (64%, 3); ascitic tap (57%, 3). Only 25% of the trainees have attended certified training courses on these skills during their Foundation Year training. More than half of these trainees (73%) found the courses very useful. Ninety-two per cent of trainees who did not attend practical skill courses are very interested to attend them. All the trainees agreed that these courses should be available for all the Foundation Year doctors, and 92% believe that these courses are most beneficial during the Foundation Year 1 training.

Conclusion

Most Foundation Year trainees have low confidence and exposure to these important practical skills. Certified practical skills courses should be made available to the Foundation Year doctors for the benefit of their training. This will also increase the quality of patient care.

Is surgical resident comfort level associated with experience?

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) has placed great emphasis on residents learning to identify their training needs and to develop learning strategies to address these needs. In surgery, residents can play an active role in identifying training needs through self-assessment of their procedural skills. Our study contributes to the growing body of literature regarding practice-based learning and improvement by attempting to determine if surgery resident experience is associated with comfort level and perceived training needs.

METHODS

Twenty-five general surgery residents completed a surgical experience survey, which asked them to indicate the range of times they performed a procedure, their comfort level in performing the procedure, and the quality of training they felt they received. Residents were given a survey with cases appropriate for their postgraduate year. A Cochran-Armitage trend test was used to evaluate the trends between comfort level and experience, and training needs and experience. A P value of 0.05 was considered statistical significance in all analyses.

RESULTS

Resident comfort level demonstrated a positive trend compared with case volume both in the self-reported survey and ACGME case log (P values<0.001). Additionally, higher levels of training were associated with increased comfort level (P value=0.05). Perceived training needs and experience were also associated (P value<0.001), demonstrating that with increased experience, residents felt that their training needs were being met.

CONCLUSION

Our study demonstrates that residents are able to assess their comfort level and training needs based on both actual and perceived experience. The procedural survey has been a useful tool for resident self-assessment in that residents are able to play a more active role in their education by developing appropriate learning plans.

They just don't get enough! Variable intern experience in bedside procedural skills

BACKGROUND

Medical school and resident training programmes offer different learning opportunities and outcomes. The aim of the study was to assess medical student and intern experience in common clinical procedures.

METHODS

Interns employed in a metropolitan teaching hospital from 2000 to 2004 completed a survey of experience and confidence in clinical procedures at the beginning and end of their intern year. Attendance at and the contribution to procedural confidence of a voluntary procedural skill-training programme were examined.

RESULTS

For the 314 interns, clinical experience before and during internship varied for each procedure and between year cohorts as did training programme attendance (44-84%). Student procedural confidence was predicted by pre-intern experience either on patients or by simulation (beta = 0.17, 95% confidence interval (CI) 0.02-0.21, P = 0.03) and age >30 years on commencing internship (beta = 8.44, 95%CI 3.03-14.06, P = 0.003. Adjusted R(2) = 0.08, P = 0.002). Intern procedural confidence by year's end was predicted by attendance at the training programme (beta = 0.48, 95%CI 0.34-0.62, P < 0.001), intern experience with patient procedures (beta = 0.34, 95%CI 0.21-0.47, P < 0.001) and a clear decision to enter a postgraduate training programme (beta = 0.13, 95%CI 0.04-0.22, P = 0.007, Adjusted R(2) = 0.50, P < 0.001).

CONCLUSION

Interns and students receive variable experience to carry out procedural skills on patients. This makes designing training programmes difficult as training needs vary each year. Both mandatory supervision of key skills and opportunities to supplement limited experience are needed during the intern year to ensure a uniform experience.

Self-rated preparedness of Australian prevocational hospital doctors for emergencies

OBJECTIVE

To determine perceived preparedness of Australian hospital-based prevocational doctors for resuscitation skills and management of emergencies, and to identify differences between doctors who perceive themselves well prepared and those who perceive themselves poorly prepared for emergencies, in demographics and exposure to desired learning methods.

METHODS

Questionnaire consisting of a mix of graded Likert scales and free-text answers distributed to 36 Australian hospitals for secondary distribution to hospital medical officers.

RESULTS

From 2607 questionnaires posted, 470 (18.1%) were returned. Thirty-one per cent (95% confidence interval [CI] 26-35%) felt well prepared for resuscitation and management of emergencies, 41% (CI 37-45%) felt adequately prepared and 28% (CI 24-32%) felt they were not well prepared. Those who felt well prepared reported that they had experienced more exposure to a range of educational methods, including consultant contact, supervisor feedback, clinical skills, high fidelity simulator sessions and unit meetings. Well-prepared and poorly prepared doctors had similar opinions of the usefulness of various learning methods, but the poorly prepared group more frequently expressed a desire for increased exposure to contact with registrars and consultants, clinical skills sessions and hospital and unit meetings. There were no differences in gender, age or country of origin (Australia vs international medical graduates) between those who felt well or poorly prepared.

CONCLUSIONS

Many prevocational hospital doctors feel inadequately prepared for the management of emergencies. Perceived preparedness is associated with more exposure to particular educational activities. Increasing exposure to learning of emergencies in undergraduate and prevocational years could reduce the number of junior doctors who feel poorly prepared for emergencies.

Resident exposure to critical patients in a pediatric emergency department

OBJECTIVES

We hypothesize that nonpediatric and pediatric residents are exposed to a very low percentage of critically ill patients in a high-volume children's hospital emergency department (ED).

METHODS

Retrospective chart review of resident-patient encounters during a 1-year period using a patient tracking system. Critically ill patients included those who were triaged as "critical," died in the ED, or admitted to the intensive care unit. Descriptive data are presented as means +/- SD, frequencies, and percentages. Analysis of variance was used for continuous data and the chi test for categorical data.

RESULTS

A total of 3048 (4.2% of the total ED volume) critically ill patients with a mean age of 6 (+/- 5.6) years were evaluated. One hundred four emergency medicine (EM) residents were involved in the care of 903 (30%), 136 pediatric residents managed 2003 (65%), and 36 family medicine residents managed 142 (5%) critically ill patients. There was no significant difference in the mean age of evaluated patients compared by type of training program. On average, EM residents evaluated 5 patients per 10 shifts compared with pediatric residents ([9 patients per 10 shifts] P < 0.0001). Unlike pediatric residents, the number of patients cared for by EM or family medicine residents did not increase with the level of resident training. Sixty-seven life-saving procedures were performed, of which 32 (48%) were cardiopulmonary resuscitations and 35 (52%) were intubations.

CONCLUSIONS

Pediatric and nonpediatric residents who rotate through a high-volume children's hospital ED are exposed to a very low number of critically ill children. Other educational formats, such as mock resuscitations or standardized patient encounters, may be required to correct this deficit.

Ontario Radiation Oncology Residents’ Needs in the First Postgraduate Year-Residents’ Perspective Survey

PURPOSE

To assess radiation oncology residents' needs and satisfaction in their first postgraduate year (PGY-1) in the province of Ontario.

METHODS AND MATERIALS

Of 62 radiation oncology residents, 58 who had completed their PGY-1 and were either enrolled or had graduated in 2006 were invited to participate in a 31-item survey. The questionnaire explored PGY-1 residents' needs and satisfaction in four domains: clinical workload, faculty/learning environment, stress level, and discrimination/harassment. The Fisher's exact and Wilcoxon nonparametric tests were used to determine relationships between covariate items and summary scores.

RESULTS

Of 58 eligible residents, 44 (75%) responded. Eighty-four percent of residents felt that their ward and call duties were appropriate. More than 50% of respondents indicated that they often felt isolated from their radiation oncology program. Only 77% agreed that they received adequate feedback, and 40% received sufficient counseling regarding career planning. More than 93% of respondents thought that faculty members had contributed significantly to their learning experience. Approximately 50% of residents experienced excessive stress and inadequate time for leisure or for reading the medical literature. Less than 10% of residents indicated that they had been harassed or experienced discrimination. Eighty-three percent agreed or strongly agreed that their PGY-1 experience had been outstanding.

CONCLUSIONS

Most Ontario residents were satisfied with their PGY-1 training program. More counseling by radiation oncology faculty members should be offered to help residents with career planning. The residents might also benefit from more exposure to "radiation oncology" and an introduction to stress management strategies.

Graduating medical students and emergency procedure skill teaching in Finland--does a clinical skills centre make the difference?

BACKGROUND

Since our previous study in 1997, three of five medical schools have introduced clinical skills centres.

AIMS

Aim of the present follow-up study was to assess the present status of emergency procedure skills teaching. The number of students having practical experience of the procedures and student satisfaction were used as outcome.

METHOD

An electronic questionnaire including questions concerning successful performance of eleven emergency procedures and experiences in a clinical skills centre was sent to all final year medical students in all five Finnish medical faculties. The students were asked to give global rating for the volume and quality of emergency procedural skills. The response rate was 304/448 (67.8%).

RESULTS

There were significant differences in theoretical knowledge and practical performance of procedures between students in different medical schools. The students in the university having integrated curriculum and longest experience of a clinical skills centre were most satisfied with the volume and quality of emergency procedural skills teaching (p<0.001). They also found practicing in a skills lab more useful than students in other medical schools (p<0.026).

CONCLUSIONS

The students' experience of emergency procedure has slightly improved. Early practising in a clinical skills centre seems to increase the student satisfaction with emergency skills education.

Growth of self-perceived clinical competence in postgraduate training for general practice and its relation to potentially influencing factors

OBJECTIVE

To examine the increase in self-perceived clinical competence during a three-year postgraduate training in general practice and to explore the relation between the growth of self-perceived competence and several background variables.

DESIGN

Cohort, 1995-1998.

SETTING

Three-year Postgraduate Training for General practice in the Netherlands

PARTICIPANTS

All Dutch trainees who followed postgraduate training from September 1995 to September 1998 (N=191).

INTERVENTION

We asked the trainees at the start and at the end of their postgraduate training to complete a questionnaire, which assessed their self-perceived knowledge, clinical skills and consultations skills. We collected information about potentially influencing background variables. Amongst these were variables such as: age, gender, prior medical experience, the effort someone has spent upon her/his education, insight in weak and strong areas of clinical competence and knowledge and skills levels.

MAIN OUTCOME MEASURE

Self-perceived competence.

RESULTS

A total of 127 trainees completed both questionnaires (190 at the first administration and 128 at the second one). We found statistically significant growth of self-perceived clinical competence. Self-perceived consultation skills increased more than self-perceived knowledge and clinical skills. The afore mentioned background variables did not relate in any way with the growth of self-perceived clinical competence.

CONCLUSION

This study shows that a 3-year postgraduate training in general practice enhances self-perceived clinical competence. However, we still do not know how to explain this improvement. Further study into the theoretical concept of self-assessment in medical education and into the factors contributing to the feeling of being competent, is required.

Evaluation of the usefulness of simulated clinical examination in family-medicine residency program

BACKGROUND

This study reports on an evaluation of the usefulness of the Simulated Clinical Examination (SCE) method as a means of assessing the clinical-skill competencies of entering Postgraduate year 1 (PGY1) family-medicine residents.

METHODS

PGY1 family-medicine residents participated in a SCE encompassing clinical encounters with standardized patients. Residents were asked to complete pre-evaluation and post-evaluation surveys, and faculty and residents participated in separate focus groups.

RESULTS

The SCE was perceived as a useful method during the early phases of postgraduate training for assessing clinical-skill competencies, providing constructive feedback to residents, enhancing self-awareness, and enhancing confidence.

CONCLUSIONS

This exploratory study suggests that the SCE, as an assessment method, can have beneficial effects on learning and the fostering of clinical-skill competencies during postgraduate training.

Undergraduate training in the care of the acutely ill patient: a literature review

OBJECTIVE

To characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions.

DESIGN

Systematic literature review including Medline, EMBASE, CINAHL. Eligible studies described education and training issues focusing on caring for acutely ill patients. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation.

MEASUREMENT AND RESULTS

We identified and reviewed 374 articles focusing on training or clinical aspects of caring for the acutely ill patient. Undergraduates and junior physicians lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient. There is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students. Many centres are starting to use an integrated approach to acute care teaching, with early exposure to basic life support and clinical skills, coupled with later exposure to more complex acute care topics. Clinical attachments remain a popular method for training in acute care. Acute care courses are increasingly being used to standardise delivery of practical skills and patient management training.

CONCLUSION

The training of healthcare staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care.

'Losing my touch': decline in self-reported confidence in performing practical procedures in consultant oncologists

This study aimed to compare the confidence of oncology consultants and specialist registrars (SpRs) in the performance of practical procedures, to contrast this with confidence in other areas of practice and to determine at what grade they felt most confident. Questionnaires were sent to all 57 oncology consultants and SpRs in the South-West region. Respondents scored confidence on a five-point Likert scale. The response rate was 70%. SpRs were significantly more confident in cardiopulmonary resuscitation (p = 0.003) and central line insertion (p = 0.006). Consultants were significantly more confident in developing management plans (p = 0.001) and performing committee work (p = 0.002). Only 6% of consultants felt most confident performing practical procedures as a consultant, and were less confident about these than other tasks (p = 0.001). Some 86% of SpRs considered they were more confident performing practical procedures as senior house officers (SHOs). In conclusion, self-reported confidence in performing practical procedures declines during career progression in oncology. This raises questions about the teaching and supervision of these procedures. If there is a greater emphasis on a consultant-provided service, their educational needs will need to be recognized and retraining or outsourcing of these procedures to other specialties may be necessary.

Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine

BACKGROUND

The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes.

METHODS

Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes.

RESULTS

Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1-8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10-11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter.

CONCLUSION

The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.

Dynamic confidence during simulated clinical tasks

OBJECTIVE

Doctors' confidence in their actions is important for clinical performance. While static confidence has been widely studied, no study has examined how confidence changes dynamically during clinical tasks.

METHOD

The confidence of novice (n = 10) and experienced (n = 10) trainee anaesthetists was measured during two simulated anaesthetic crises, bradycardia (easy task) and failure to ventilate (difficult task).

RESULTS

As expected, confidence was high in the novice and experienced groups in the easy task. What was surprising, however, was that confidence during the difficult task decreased for both groups, despite appropriate performance.

CONCLUSIONS

Given that confidence affects performance, it is alarming that doctors who may be acting unsupervised should lose dynamic confidence so quickly. Training is needed to ensure that confidence does not decrease inappropriately during a correctly performed procedure. Whether time on task interacts with incorrect performance to produce further deficits in confidence should now be investigated.

Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence

BACKGROUND

The intern year is a key time for the acquisition of clinical skills, both procedural and cognitive. We have previously described self-reported confidence and experience for a number of clinical skills, finding high levels of confidence among Australian junior doctors. This has never been correlated with an objective measure of competence.

AIMS AND HYPOTHESIS

We aimed to determine the relationship between self-reported confidence and observed competence for a number of routine, procedural clinical skills.

METHODS

A group of 30 junior medical officers in their first postgraduate year (PGY1) was studied. All subjects completed a questionnaire concerning their confidence and experience in the performance of clinical skills. A competency-based assessment instrument concerning 7 common, practical, clinical skills was developed, piloted and refined. All 30 PGY1s then completed an assessment using this instrument. Comparisons were then made between the PGY1s' self-reported levels of confidence and tutors' assessments of their competence.

RESULTS

A broad range of competence levels was revealed by the clinical skills assessments. There was no correlation between the PGY1s' self-ratings of confidence and their measured competencies.

CONCLUSIONS

Junior medical officers in PGY1 demonstrate a broad range of competence levels for several common, practical, clinical skills, with some performing at an inadequate level. There is no relationship between their self-reported level of confidence and their formally assessed performance. This observation raises important caveats about the use of self-assessment in this group.

The transition from knowing to doing: teaching junior doctors how to use insulin in the management of diabetes mellitus

OBJECTIVE

To develop and evaluate a short education programme to improve the skills and confidence of junior doctors in managing the glycaemic control of inpatients with diabetes mellitus.

METHODS

A total of 15 junior doctors completed two 1-hour workshops on the practical skills required to manage the glycaemic control of insulin-treated patients. The workshops were based on simulated case scenarios presented in a workbook format. Pre-workshop performance and levels of confidence were tested, using a set of tasks matched to the learning objectives. Participants were re-tested immediately after the second workshop and again after 3 months.

RESULTS

There was a significant overall effect for time of testing for performance and confidence considered together, F(4,11) = 12.67, P = 0.000, power = 1.00. The mean score for performance for the intermediate and 3-month post-tests combined was significantly higher than the mean performance score for the pre-test (11.00 < [17.53 + 15.80]), t(56) = -6.50, P = 0.000 (95% CI -6.15, -3.10). The mean score for confidence for the intermediate and 3 month post-tests combined was higher than the mean for the pre-test (13.20 < [15.33 + 15.20]), t(56) = 2.95, P = 0.011 (95% CI 2.19, 0.46), although this result must be treated with caution.

CONCLUSIONS

A brief educational intervention can improve and maintain the performance and confidence of junior doctors in managing patients with insulin-treated diabetes in a simulated environment.

Building confidence for work as house officers: student experience in the final year of a new problem-based curriculum

INTRODUCTION

Newly qualified doctors require an appropriate level of confidence for their new roles. Development of this confidence was a key objective in the final year of a new integrated course with an emphasis on student self-direction.

CONTEXT

There are 5 placements in the final year course. Students use a Learning Planner to help them choose suitable placements and objectives to serve their learning needs. Educational supervision focuses on helping students determine their objectives and assessing them against these.

METHODS

Course evaluation was by means of a questionnaire during final assessments. Cohorts of 310 and 316 students in successive years completed the evaluation. The interrelationship between variables was explored using logistic regression.

RESULTS

220/310 students in the 2000 cohort and 214/316 in the 2001 cohort agreed they felt confident with their prospective role as a pre-registration house officer (PRHO). Confidence was significantly associated with confidence in their clinical skills, belief in their ability to cope with uncertainty and feeling able to work as a team member. The experience of the 2 hospital placements and (in 2000 only) the elective was associated with increased confidence. In all placements helpful educational supervision and the achievement of the self-directed learning plan was associated with increased confidence as a potential doctor.

CONCLUSION

Students perceive a relationship between learning experiences in the final year of a self-directed course and development of confidence for their future role. Whilst further elucidation of the nature of this relationship is required, this provides encouragement to curriculum planners to promote self-direction.

Undergraduate student nurses' expectations and their self-reported preparedness for the graduate year role

AIMS OF THE STUDY

The study identifies third-year nurses' expectations of the graduate nurse role and ascertains how prepared they feel to fulfil this role.

BACKGROUND

The literature substantiates that the university-workplace transition is marked by differences between students' expectations of the graduate year and the realities of practice they encounter in the workforce setting. Nursing professionals and health service employers continue to debate the expectations required of the new nurse graduate. Yet there is little assessment of graduate nurses' expectations of the workplace. This study describes student nurses' expectations of the graduate year and the extent to which they regard themselves as well- or ill-prepared.

DESIGN

Third-year student nurses (n=105) from a 3-year Bachelor of Nursing (BN) course at a large Metropolitan University in Australia were surveyed. A group of nursing academics and their senior colleagues in the clinical setting designed a questionnaire in light of common themes derived from literature on the graduate year role. Responses were examined and analysed using descriptive statistics.

RESULTS

Responses revealed that student nurses tended to favour large public hospitals, and sought a good graduate programme with associated opportunities for guidance and support. Most expected to achieve good working relationships with both professional colleagues and patients. Final year students expressed some apprehension about meeting the performance expectations of the workplace, given their self-perceived lack of clinical experience.

CONCLUSION

When asked about their initial expectations of the workplace, third year student nurses expressed little apprehension and reported high levels on scales of organizational commitment and professionalism. The research literature suggests that divisions exist between students' expectations of the graduate year and the actual work experience. The expectations of the graduate year described in this study offer a student-centred perspective that contributes to future planning and policy directions of undergraduate curricula, graduate year programmes and nurse retention.